FCCN LEVEL 1 EXAM WITH COMPLETE
SOLUTIONS.
Introduction
This 150-item simulation mirrors the 2025 Society of Critical Care Medicine (SCCM)
Fundamental Critical Care Support (FCCS) Level 1 certification examination.
Content spans seven weighted domains: recognition & management of critically ill
patients, airway & ventilator support, shock & hemodynamic monitoring, trauma &
neurological emergencies, infection control & sepsis, metabolic & electrolyte disorders,
and ICU protocols & patient safety.
Every question is original, scenario-based, and aligned with current SCCM evidence-
based guidelines to support mastery-level performance.
Examination-length set: 150 original questions
Question 1:
A 67-year-old male presents to the ED with acute dyspnea, SpO₂ 82 % on room air, and
audible stridor. BP 190/110 mmHg, HR 118 min⁻¹, RR 32 min⁻¹. Which immediate
assessment is most critical?
A. Obtain chest X-ray
B. Measure peak expiratory flow
C. Assess airway patency and vocal cord motion
D. Administer IV furosemide
Answer: C. Assess airway patency and vocal cord motion
Solution: Stridor signals upper-airway obstruction; airway evaluation precedes imaging
or diuretics. Chest X-ray (A) delays definitive care, PEF (B) is for lower-airway
obstruction, furosemide (D) treats pulmonary edema—not obstruction.
Question 2:
A patient on mechanical ventilation (VC-AC, TV 450 mL, PEEP 5 cmH₂O, FiO₂ 0.4)
suddenly desaturates to SpO₂ 88 %. Plateau pressure rises from 22 to 38 cmH₂O. Which
intervention is most appropriate?
A. Increase FiO₂ to 0.8
B. Suction endotracheal tube
C. Add extrinsic PEEP
D. Reduce TV to 300 mL
Answer: B. Suction endotracheal tube
Solution: Sudden rise in plateau with desaturation suggests tube occlusion or mucus
,plug—suction first. Increasing FiO₂ (A) does not relieve obstruction, adding PEEP (C)
worsens auto-PEEP, TV reduction (D) is secondary.
Question 3:
A 54-year-old female post-MI develops cool mottled skin, urine output 15 mL/h, MAP 58
mmHg, CVP 14 mmHg, cardiac index 1.9 L/min/m². Which shock type is most likely?
A. Hypovolemic
B. Distributive
C. Cardiogenic
D. Obstructive
Answer: C. Cardiogenic
Solution: Low CI, high CVP, low MAP, and oliguria indicate primary pump failure.
Hypovolemic (A) would show low CVP, distributive (B) high CI/low SVR, obstructive (D)
equalization of pressures (tamponade/PE).
Question 4:
A trauma patient arrives with GCS 10, BP 80/50 mmHg, HR 130 min⁻¹, RR 28 min⁻¹.
FAST exam shows free fluid in Morrison’s pouch. Which priority aligns best with ATLS?
A. Immediate CT abdomen
B. Type and cross-match 6 units PRBC
C. Transport to OR for exploratory laparotomy
D. Insert central line prior to departure
Answer: C. Transport to OR for exploratory laparotomy
Solution: Positive FAST + hemodynamic instability = operative emergency; delay for CT
(A) or line (D) increases mortality. Cross-match (B) is concurrent, not the highest
priority.
Question 5:
A 72-year-old male with COPD has ABG: pH 7.18, PaCO₂ 85 mmHg, PaO₂ 55 mmHg on 4
L/min nasal cannula. He is drowsy. Which next step is most appropriate?
A. Increase nasal cannula to 6 L/min
B. Start non-invasive ventilation (NIV)
C. Administer IV naloxone
D. Begin high-flow nasal cannula at 60 L/min
Answer: B. Start non-invasive ventilation (NIV)
Solution: Acute hypercapnic respiratory failure with acidosis and altered mental status
is an NIV indication. Increasing O₂ (A, D) may worsen hypercapnia, naloxone (C) is for
narcotic overdose—no indication here.
,Question 6:
A patient on norepinephrine 0.3 µg/kg/min has MAP 65 mmHg, ScvO₂ 78 %, lactate 1.5
mmol/L. Which intervention is most appropriate?
A. Increase norepinephrine to 0.5 µg/kg/min
B. Add vasopressin 0.03 units/min
C. Start dobutamine 5 µg/kg/min
D. Begin fluid challenge 500 mL
Answer: D. Begin fluid challenge 500 mL
Solution: ScvO₂ ≥ 70 % and low lactate suggest adequate oxygen delivery; hypotension
may reflect hypovolemia. Escalating vasopressors (A, B) or inotrope (C) without volume
assessment risks unnecessary vasoconstriction.
Question 7:
A 60 kg patient receives 50 mL of 10 % calcium gluconate for hypocalcemia. Which
immediate monitoring is most important?
A. Serum phosphate
B. QT interval on ECG
C. Blood pressure every 15 min
D. Urine output hourly
Answer: B. QT interval on ECG
Solution: Calcium repletion shortens QT and prevents torsades; ECG is the most
sensitive indicator of effect. Phosphate (A) lags, BP (C) is rarely altered, urine (D)
reflects global perfusion, not calcium effect.
Question 8:
A patient with severe ARDS (PaO₂/FiO₂ 85 mmHg) on VC-AC, PEEP 15 cmH₂O, FiO₂ 0.8
has plateau pressure 32 cmH₂O. Which ventilator adjustment best aligns with lung-
protective strategy?
A. Increase PEEP to 18 cmH₂O
B. Reduce TV to 4 mL/kg PBW
C. Switch to pressure-control ventilation
D. Increase RR to 35 min⁻¹
Answer: B. Reduce TV to 4 mL/kg PBW
Solution: ARDSNet targets plateau ≤ 30 cmH₂O; lowering TV achieves this while
limiting volutrauma. Increasing PEEP (A) may raise plateau, PC-CMV (C) is mode-
neutral, high RR (D) risks auto-PEEP.
Question 9:
A patient with DKA has pH 6.9, HCO₃ 5 mmol/L, glucose 38 mmol/L, K⁺ 3.2 mmol/L.
Which order is most urgent after starting fluids?
, A. 10 units regular insulin IV bolus
B. Initiate bicarbonate infusion
C. Begin potassium replacement
D. Start magnesium sulfate
Answer: C. Begin potassium replacement
Solution: Insulin will drive K⁺ intracellularly; replete to ≥ 3.5 mmol/L before insulin to
avoid life-threatening hypokalemia. Bicarbonate (B) is not recommended unless pH <
6.8 with hemodynamic instability, magnesium (D) is adjunctive.
Question 10:
A patient on broad-spectrum antibiotics develops profuse watery diarrhea and fever. C.
difficile toxin PCR is positive. Which isolation precaution is most appropriate?
A. Standard precautions only
B. Contact precautions plus single room
C. Droplet precautions
D. Airborne precautions
Answer: B. Contact precautions plus single room
Solution: C. difficile spores spread by direct contact; contact precautions and
environmental cleaning are essential. Droplet (C) and airborne (D) are unnecessary,
standard (A) insufficient.
Question 11:
A patient with septic shock has MAP 55 mmHg on norepinephrine 0.4 µg/kg/min and
adequate filling pressures. Which adjunct vasopressor is best supported by guidelines?
A. Phenylephrine
B. Dopamine
C. Vasopressin 0.03 units/min
D. Epinephrine
Answer: C. Vasopressin 0.03 units/min
Solution: VASST and SSC guidelines suggest adding low-dose vasopressin to reduce
catecholamine exposure. Phenylephrine (A) lacks evidence, dopamine (B) increases
arrhythmia risk, epinephrine (D) is second-line but not adjunctive at low dose.
Question 12:
A patient with acute ischemic stroke (NIHSS 18) arrives 5 hours after onset. BP 190/100
mmHg. Which BP target is most appropriate before potential thrombolysis?
A. Reduce to < 185/110 mmHg
B. Reduce to < 160/90 mmHg
C. Maintain 140–160 mmHg
D. Allow spontaneous decline
SOLUTIONS.
Introduction
This 150-item simulation mirrors the 2025 Society of Critical Care Medicine (SCCM)
Fundamental Critical Care Support (FCCS) Level 1 certification examination.
Content spans seven weighted domains: recognition & management of critically ill
patients, airway & ventilator support, shock & hemodynamic monitoring, trauma &
neurological emergencies, infection control & sepsis, metabolic & electrolyte disorders,
and ICU protocols & patient safety.
Every question is original, scenario-based, and aligned with current SCCM evidence-
based guidelines to support mastery-level performance.
Examination-length set: 150 original questions
Question 1:
A 67-year-old male presents to the ED with acute dyspnea, SpO₂ 82 % on room air, and
audible stridor. BP 190/110 mmHg, HR 118 min⁻¹, RR 32 min⁻¹. Which immediate
assessment is most critical?
A. Obtain chest X-ray
B. Measure peak expiratory flow
C. Assess airway patency and vocal cord motion
D. Administer IV furosemide
Answer: C. Assess airway patency and vocal cord motion
Solution: Stridor signals upper-airway obstruction; airway evaluation precedes imaging
or diuretics. Chest X-ray (A) delays definitive care, PEF (B) is for lower-airway
obstruction, furosemide (D) treats pulmonary edema—not obstruction.
Question 2:
A patient on mechanical ventilation (VC-AC, TV 450 mL, PEEP 5 cmH₂O, FiO₂ 0.4)
suddenly desaturates to SpO₂ 88 %. Plateau pressure rises from 22 to 38 cmH₂O. Which
intervention is most appropriate?
A. Increase FiO₂ to 0.8
B. Suction endotracheal tube
C. Add extrinsic PEEP
D. Reduce TV to 300 mL
Answer: B. Suction endotracheal tube
Solution: Sudden rise in plateau with desaturation suggests tube occlusion or mucus
,plug—suction first. Increasing FiO₂ (A) does not relieve obstruction, adding PEEP (C)
worsens auto-PEEP, TV reduction (D) is secondary.
Question 3:
A 54-year-old female post-MI develops cool mottled skin, urine output 15 mL/h, MAP 58
mmHg, CVP 14 mmHg, cardiac index 1.9 L/min/m². Which shock type is most likely?
A. Hypovolemic
B. Distributive
C. Cardiogenic
D. Obstructive
Answer: C. Cardiogenic
Solution: Low CI, high CVP, low MAP, and oliguria indicate primary pump failure.
Hypovolemic (A) would show low CVP, distributive (B) high CI/low SVR, obstructive (D)
equalization of pressures (tamponade/PE).
Question 4:
A trauma patient arrives with GCS 10, BP 80/50 mmHg, HR 130 min⁻¹, RR 28 min⁻¹.
FAST exam shows free fluid in Morrison’s pouch. Which priority aligns best with ATLS?
A. Immediate CT abdomen
B. Type and cross-match 6 units PRBC
C. Transport to OR for exploratory laparotomy
D. Insert central line prior to departure
Answer: C. Transport to OR for exploratory laparotomy
Solution: Positive FAST + hemodynamic instability = operative emergency; delay for CT
(A) or line (D) increases mortality. Cross-match (B) is concurrent, not the highest
priority.
Question 5:
A 72-year-old male with COPD has ABG: pH 7.18, PaCO₂ 85 mmHg, PaO₂ 55 mmHg on 4
L/min nasal cannula. He is drowsy. Which next step is most appropriate?
A. Increase nasal cannula to 6 L/min
B. Start non-invasive ventilation (NIV)
C. Administer IV naloxone
D. Begin high-flow nasal cannula at 60 L/min
Answer: B. Start non-invasive ventilation (NIV)
Solution: Acute hypercapnic respiratory failure with acidosis and altered mental status
is an NIV indication. Increasing O₂ (A, D) may worsen hypercapnia, naloxone (C) is for
narcotic overdose—no indication here.
,Question 6:
A patient on norepinephrine 0.3 µg/kg/min has MAP 65 mmHg, ScvO₂ 78 %, lactate 1.5
mmol/L. Which intervention is most appropriate?
A. Increase norepinephrine to 0.5 µg/kg/min
B. Add vasopressin 0.03 units/min
C. Start dobutamine 5 µg/kg/min
D. Begin fluid challenge 500 mL
Answer: D. Begin fluid challenge 500 mL
Solution: ScvO₂ ≥ 70 % and low lactate suggest adequate oxygen delivery; hypotension
may reflect hypovolemia. Escalating vasopressors (A, B) or inotrope (C) without volume
assessment risks unnecessary vasoconstriction.
Question 7:
A 60 kg patient receives 50 mL of 10 % calcium gluconate for hypocalcemia. Which
immediate monitoring is most important?
A. Serum phosphate
B. QT interval on ECG
C. Blood pressure every 15 min
D. Urine output hourly
Answer: B. QT interval on ECG
Solution: Calcium repletion shortens QT and prevents torsades; ECG is the most
sensitive indicator of effect. Phosphate (A) lags, BP (C) is rarely altered, urine (D)
reflects global perfusion, not calcium effect.
Question 8:
A patient with severe ARDS (PaO₂/FiO₂ 85 mmHg) on VC-AC, PEEP 15 cmH₂O, FiO₂ 0.8
has plateau pressure 32 cmH₂O. Which ventilator adjustment best aligns with lung-
protective strategy?
A. Increase PEEP to 18 cmH₂O
B. Reduce TV to 4 mL/kg PBW
C. Switch to pressure-control ventilation
D. Increase RR to 35 min⁻¹
Answer: B. Reduce TV to 4 mL/kg PBW
Solution: ARDSNet targets plateau ≤ 30 cmH₂O; lowering TV achieves this while
limiting volutrauma. Increasing PEEP (A) may raise plateau, PC-CMV (C) is mode-
neutral, high RR (D) risks auto-PEEP.
Question 9:
A patient with DKA has pH 6.9, HCO₃ 5 mmol/L, glucose 38 mmol/L, K⁺ 3.2 mmol/L.
Which order is most urgent after starting fluids?
, A. 10 units regular insulin IV bolus
B. Initiate bicarbonate infusion
C. Begin potassium replacement
D. Start magnesium sulfate
Answer: C. Begin potassium replacement
Solution: Insulin will drive K⁺ intracellularly; replete to ≥ 3.5 mmol/L before insulin to
avoid life-threatening hypokalemia. Bicarbonate (B) is not recommended unless pH <
6.8 with hemodynamic instability, magnesium (D) is adjunctive.
Question 10:
A patient on broad-spectrum antibiotics develops profuse watery diarrhea and fever. C.
difficile toxin PCR is positive. Which isolation precaution is most appropriate?
A. Standard precautions only
B. Contact precautions plus single room
C. Droplet precautions
D. Airborne precautions
Answer: B. Contact precautions plus single room
Solution: C. difficile spores spread by direct contact; contact precautions and
environmental cleaning are essential. Droplet (C) and airborne (D) are unnecessary,
standard (A) insufficient.
Question 11:
A patient with septic shock has MAP 55 mmHg on norepinephrine 0.4 µg/kg/min and
adequate filling pressures. Which adjunct vasopressor is best supported by guidelines?
A. Phenylephrine
B. Dopamine
C. Vasopressin 0.03 units/min
D. Epinephrine
Answer: C. Vasopressin 0.03 units/min
Solution: VASST and SSC guidelines suggest adding low-dose vasopressin to reduce
catecholamine exposure. Phenylephrine (A) lacks evidence, dopamine (B) increases
arrhythmia risk, epinephrine (D) is second-line but not adjunctive at low dose.
Question 12:
A patient with acute ischemic stroke (NIHSS 18) arrives 5 hours after onset. BP 190/100
mmHg. Which BP target is most appropriate before potential thrombolysis?
A. Reduce to < 185/110 mmHg
B. Reduce to < 160/90 mmHg
C. Maintain 140–160 mmHg
D. Allow spontaneous decline
